Development of Visiting Professor Role to Nursing Home Group: Providing Sustainable Education for Older Person Care

This paper explores the process involved in the development, in 2021, of a new role of visiting professor to Nursing Homes Ireland (NHI), in collaboration with the Faculty of Nursing and Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences. The role was developed following the Covid 19 pandemic and will support the NHI National Nursing Committee in identifying their needs and that of the society it serves by providing leadership, research and education programmes that are aligned to the university and the NHI members’ values. An evidence review was undertaken to identify studies relating to older person care and the impact of Covid 19 on nursing home residents during and following the Covid-19 pandemic. A cross-sectional on-line survey was undertaken in 2022, to capture educational needs and perceptions about work environment with a sample of 65 NHI staff representing all grades. This was followed by two


Introduction
The overarching aim of this visiting professor appointment is to support the continuing education and policy development of the NHI National Nursing Committee. To this aim a Memorandum of Agreement was drawn up, in 2016, between NHI and the Faculty of Nursing and Midwifery, RCSI University of Medicine and Health Sciences. The MOU was signed by the dean of faculty, faculty executive director and NHI group CEO. This agreement instigated communication and collaboration between both parties, resulting in a faculty academic being appointed as visiting professor to the group, in 2021. This is the first such appointment in Ireland and is now part of the visiting professor's work in the faculty, which includes research and education.
RCSI has been at the forefront of educating healthcare professionals since 1784 when the college was founded as the national training and professional body for surgery. Today RCSI is Ireland's only focused health sciences institution, Ireland's largest medical school and one of the leading health sciences institutions in the World. The RCSI Faculty of Nursing and Midwifery was established in 1974, under the leadership of Ms. Mary Frances Crowley, First Dean. A wide range of professional development programmes and leading edge research is being undertaken by the faculty.
Nursing Homes Ireland (NHI) is the national representative body for the private and voluntary nursing home sector, involving 380 nursing homes in Ireland, providing care to over 25,000 people. NHI mission is to actively support and represent members, enabling them to provide sustainable, high quality care to residents. Nursing homes form a vital part of the tapestry of the Irish health system and are a critical component of a well-functioning health service. NHI members provide compassionate, high-quality, residential care to its most vulnerable population. Residents' day-to-day needs are met in a supportive, non-medicalised, and non-acute environment. Currently there are over 32,000 registered nursing home beds in Ireland of which 80% are private and voluntary, with the balance operated by the Health Service Executive (HSE). According to the Accenture Report (2022) an estimated 7,500 additional nursing home beds are required to be delivered by 2026, simply to address the projected population growth [1].

Evidence Review
Cooper's (1989) five stage approach, with revision, guided this review: concept/project formulation, data collection, evaluation of data for suitability, data analysis and interpretation and presentation of results. The evidence review identified that the Covid-19 pandemic has significantly impacted on nursing home care and on the care being provided by all nursing home staff. On 11 March 2020, the World Health Organization characterised COVID-19 as a pandemic [2] and the first case of the virus in the ROI was confirmed on 29 February [3], and the first notification to the Department of Health of a suspected/ confirmed outbreak of COVID-19 in a nursing home in Ireland was received on the 13th March [4]. By mid-July the pandemic had had a disproportionate impact on residents in care settings for older people with 56% of all deaths (1748) occurring in this population (Health Protection Surveillance Centre, https://www.hpsc.ie/). A COVID-19 Nursing Home Expert Panel was established by the Minister for Health in May 2020 and published their report in August 2020 [5]. The report highlighted multiple areas for improvement includinginfection prevention and control, management, visiting, staffing and workforce, education, GP roles, regulations and statutory care supports for older people. Ireland is not unique in this finding. Daly's study of COVID-19 in nursing homes in the UK points to years of austerity and resource cutting, weak regulation and the depoliticisation of social care with an accompanying pre-eminence of acute/medically focused state National Health Service (NHS) system [6]. Leadership by directors of nursing was also recognised by Daly [7] in his statement: "Confronted directly by a pandemic, Directors of Nursing applied tremendous leadership, intensifying the application of infection, prevention and control practices that resulted in nursing homes transforming from social to more medical models. The pandemic must represent a defining moment for gerontological care. This means a requirement for the State to recognise the expertise entailed in providing high-standard nursing home care and to ensure that an appropriate framework is implemented to appropriately recognise and value the specialised care needed [7].
The COVID-19 pandemic had a disproportionate effect in residential care settings for older people in Ireland [3]. An online survey administered after the first wave of the virus to staff, residents and family members and one-to-one interviews with family members shortly after wave 2 of the virus by Sweeney et al. [3] found that isolation, loss of connectedness and reduction in the level/quality of care provision led to significant adverse impacts for both residents and their families. Staff reported high levels of stress, trauma and burnout. Family input to care was suspended, with adverse consequences and the pandemic had an adverse impact on residents, family members and staff in care settings for older people.
The adverse effects of the pandemic on the social functioning and mental health of a range of populations has been widely reported [8]. Older people, and particularly those in residential care were further socially isolated and unable to access alternative measures of psychological support due to cocooning guidelines and visitor/contact restrictions in residential care [9]. The high Volume  levels and detrimental effects of isolation among nursing home residents in COVID-19 has been reported elsewhere [10,11].
In preparing for this role a search of relevant literature was undertaken. Findings provided the way forward. The evidence review identified studies relating to ageing and its impact during the Covid-19 pandemic. An analysis of the expert national public health emergency teams report indicated 86 recommendations relating to the nursing home sector and provided essential considerations for their effective implementation [12]. Evidence review identified the programmes that are most relevant to the visiting professor role. These include strategic planning and education to enable nursing homes to meet the needs of the residents and regulatory requirements. Studies point to the need for falls education and care of the resident with dementia. Tan and Seetharaman identify the challenges for people with dementia and communication/behavioural issues in the context of the pandemic and report an increase in restraint use and falls due to imposed isolation [13]. Those areas form part of the education programme being delivered to NHI members.

Important evidence identified related to the Irish
Longitudinal Study on Ageing (TILDA), undertaken in Trinity College, which examined the impact of the COVID-19 pandemic on the lives of older adults. The study recognised that nurses, with their comprehensive education and clinical training are ideally positioned to provide care to residents during more acute phases of illness. It also recognised that nurses with support from healthcare assistants and medical practitioners can be at the forefront of developing and leading on a new model for nursing home care delivery in Ireland.
The visiting professor role was also guided by a study that called for better supports for nursing home staff and further integration of care homes into the wider healthcare system [7]. The work of the All-Ireland Gerontological Nurses Association stated that directors of nursing have to be able to balance a range of competing demands, values, strategies and regulatory frameworks in order to provide effective care services for vulnerable older people and recognised that the pandemic placed both physical and psychological demands on all nurses at this time. Evidence does support gerontology training for registered nurses or advanced practice nurses who provide direct care to patients [14]. Following this review, which also included international evidence, education and research principles for the visiting professor role were developed.

Data collection
The search strategy combined two concepts: older person care and education and research for practice. These concepts were operationalised broadly to capture as many relevant articles as possible. The review was limited to articles that were written in English and published between 2020 and 2022 and which had an abstract. The searches provided a yield of 34 papers of which 21 papers were utilised in this study.

Search history databases
Library databases that were searched included EBSCOhost, Pub Med Central, Google Scholar, Medline, CINAHL.

Evaluation of data
Results of the literature search were screened against inclusion and exclusion criteria. Articles were included if they met most, or all, of the following criteria: based on empirical research, contained an abstract, written in English, focused on older person care and nursing home care settings, placed emphasis on service users, carers, professionals and organisations involved in care of the older person.

Data analysis and interpretation
Papers were reviewed for study design, sample approach and methodology, aims presented, outcomes, relevance and recommendations. Papers reviewed were deemed to yield a greater level of information than was possible to present in this review. The majority of journal articles used either descriptivecorrelational designs or qualitative, mixed methods

Research Methods
An online anonymous survey was developed and disseminated to managers and senior nursing council and nursing staff of residential care settings for older people. A cross-sectional survey of directors of nursing (DON) PIC's, assistant directors of nursing (ADON), staff nurses and HCA's was undertaken in NHI (n = 65). Participants completed an on-line questionnaire to capture their educational needs and perceptions of their work environment. The response rate was satisfactory. Results informed the strategic direction of the education programme. Following thematic analyses of findings a qualitative study of 2 virtual focus groups (12 senior staff) was carried out with the support of the NHI strategic clinical nurse expert with regulatory compliance. Findings were thematically analysed.

Discussion
Findings from the evidence review, survey and focus groups indicate the significance of the research. This process commenced In July 2022. Following a review of the literature a Research and Education Plan which has relevance to all stakeholders was developed. Krause highlights how directors of nursing need continuing professional educational support especially during their transition into their new managerial roles, in order to develop skills in coordinating and overseeing nursing care [15]. The pandemic must represent a defining moment for gerontological care. This entails requirement for the State to appropriately recognise and value the specialised care provided within our nursing homes [7]. Riman et al., propose strategic planning to support nursing leaders which enhances their retention in the long-term care setting. The evidence review and findings for the qualitative research identified the programmes that are most relevant to the visiting professor role [16]. These include strategic planning and education to enable nursing homes to meet the needs of the residents and regulatory requirements. Responses led to the Development of a Professional Strategic Plan (2022-24) for all NHI staff, by the visiting professor and subject expert. This plan was distributed to the NHI National Nursing Committee for comment, advice and further recommendations.

Research Implementation
Education and research principles were developed for the role. The education principles are to assess, identify, reflect on, and implement transformative educational programmes for the senior nursing home nurses and other grades of staff if required. This includes the promotion of an education culture that cascades downwards to all nurses and HCA's' in its nursing homes. This will be achieved through collaborative quality assurance and quality improvements of education programmes with the nursing committee that are linked to health policy and the health need of residents.
The Research Principles for the role are to support and advise the nursing committee in research by sourcing and assessing relevant research data and information related to the education needs of NHI members and particularly its senior nursing committee, by identifying research trends and supporting staff in remaining abreast of current research into education. Principles also incorporate current research that focuses on evidence based practice into nursing education practice and delivery. Sweeney et al. recommend that strategies to ensure that residents' physical, emotional and social needs and staffs' professional and personal needs are appropriately supported during future waves of the pandemic should now be implemented [3]. These areas are now being considered also. Research is being analysed and presented in newsletters by the visiting professor for distribution monthly to senior nursing staff. Sustainable outcomes are being achieved by fostering meaningful relations with other NHI education and training programmes and expanding the digital agenda of NHI by presenting relevant webinars and seminars [17][18][19][20][21].

Conclusion
NHI National Nursing Committee members suggest their current developmental priorities (2022-2024) as leadership, strategy, advanced management, legal and ethical issues, governance, regulatory and safety. The needs of staff nurses are identified as role standards and scope of practice, competencies for care delivery, safeguarding older persons in residential care and leadership in practice.
Delivery of this programme will continue to take into account the needs and wants of staff and will be delivered at times suitable to staff. Programmes will continue to be developed and delivered by the visiting professor with the support of RCSI faculty of nursing and midwifery lecturers, NHI National Nursing Committee members and experts in the field of dementia and aged care. Integration of theory and practice will be supported by interaction and discussion. Currently the mode of delivery is interactive, virtual and over one hour duration. This short time frame takes the organisation and person's time limitations into account and may be tailored by faculty for all levels. The role of visiting professor will continue to be collaborative and programme delivery will be interactive. The views of staff and their needs and views will be carefully considered by the faculty and visiting professor thus ensuring sustainable delivery over time.